Social Skills Deficits in a Virtual Environment Among Spanish Children With ADHD

Abstract

Objective: Research assessing the social skills of children with ADHD has predominantly relied upon North American samples. In addition, most existing work has been conducted using methodology that fails to use a controlled peer stimulus; such methods may be more vulnerable to cultural influence. Method: We examined the social skills of 52 Spanish children (ages 8-12) with and without ADHD using a controlled Chat Room Task, which simulates a virtual social environment where peers’ responses are held constant, so that participants’ social skills may be assessed. Results: After statistical control of typing and reading comprehension skills, Spanish children with ADHD gave fewer prosocial comments and had greater difficulty remembering central details from the conversation between the peers, relative to comparison children. Conclusion: The virtual Chat Room Task may be useful to assess social skills deficits using a controlled paradigm, resulting in the identification of common social deficiencies cross-culturally.

Keywords

ADHD Chat Room Task social skills Spain cross-cultural

ADHD is a condition that develops in childhood, characterized by a persistent, impairing pattern of inattention and/or hyperactivity/impulsivity in multiple settings. ADHD occurs cross-culturally, with a worldwide prevalence of approximately 5.3% (Polanczyk, de Lima, Horta, Biederman, & Rohde, 2007). Specifically, ADHD has been established to exist in Spain, where a meta-analysis of 14 studies yielded an estimated prevalence of 6.8%, which is similar to that found in North America (Catalá-López et al., 2012). As well, the core symptoms of ADHD and the diagnostic criteria for this disorder are comparable in Spain and North America (Catalá-López et al., 2012).

To date, the majority of the research on ADHD has been conducted using North American samples. This bias is particularly evident in studies focusing on ADHD-related impairments (as opposed to ADHD prevalence rates; see Catalá-López et al., 2012). Yet, impairments are important to study because they represent the most frequent reason for treatment referrals (Fabiano et al., 2006), and they may persist across the life span even if the core symptoms of ADHD remit (e.g., Hinshaw et al., 2012).

A notable impairment for children with ADHD is their social functioning (Gardner & Gerdes, 2013). At least in North American samples, around 70% of children with ADHD experience peer rejection (Hoza et al., 2005), and they tend to have few reciprocated friendships (Mikami, 2010). Much research documents the social skills deficits shown by North American children with ADHD that contribute to their problems with peers (e.g., Andrade & Tannock, 2014; Gardner & Gerdes, 2013). However, as a field we know considerably less about whether similar social skills deficits exist among ADHD populations cross-culturally. Because social competence (and social problems) are highly likely to be influenced by cultural norms, such as peers’ interpretations of (and judgments made about) ADHD symptoms, it is important to examine the presence of social impairment in a cross-cultural context. The current study attempts to do so among Spanish children with ADHD.

Social Skills Problems Among Children With ADHD

Although research involving Spanish participants is scarce, the available evidence that exists suggests that Spanish children with ADHD have social impairment. Spanish children with ADHD symptoms are reported by both parents and teachers as having poorer social functioning (e.g., poorer social skills, more unexpected and inappropriate behavior, less prosocial behavior) than typically developing peers (Fernandez-Jaen et al., 2011; García, Jara, & Sánchez, 2011). In addition, García, Presentación, Siegenthaler, and Miranda (2006) found that Spanish children with ADHD were reported by classmates to have frequent negative behaviors and personality characteristics (e.g., has a bad temper, arrogant, selfish). These negative characteristics, as reported by classmates, explained 74% of the variance in peers’ disliking of children with ADHD. Also consistent with these results, Lora and Moreno (2008) found that Spanish children with elevated ADHD symptoms self-reported poorer social relationships with peers than did typically developing children. These results suggest that social problems similarly exist among Spanish children with ADHD.

Further research in North American samples suggests that the peer relationship difficulties children with ADHD face may be specifically attributable, at least in part, to their deficient social skills in social interactions such as conversations with peers (Gardner & Gerdes, 2013). Collectively, this research points to problems children with ADHD may have in detecting and encoding social cues in conversations with peers, as well as in generating and enacting appropriate responses. In regard to this topic, studies involving Spanish participants are lacking, as the limited existing research tends to suggest the presence of social impairment in Spanish ADHD populations but (with very few exceptions) does not document in what specific situations (or why) social impairment occurs. The current study attempts to address this gap in the literature by examining conversational skill problems among Spanish children with ADHD.

Following the sequence of the Social Information Processing Model (Crick & Dodge, 1994; Fontaine, 2010), accurately detecting social cues in conversation is the first step that influences children’s eventual display of socially skilled behavioral responses. Studies involving North American samples suggest that children with ADHD are impaired in this process. For instance, an old but important observational study paired boys in a “space flight” task where one boy (the mission control) had to give instructions to the other boy (the astronaut). Boys with ADHD, relative to comparison boys, were unaware of their partner’s needs, not recognizing when their partner (as the astronaut) lacked the background information to understand their instructions (Whalen, Henker, Collins, McAuliffe, & Vaux, 1979). More controlled tasks have also isolated cue encoding as a specific area of deficiency for children with ADHD. Matthys, Cuperus, and Engeland (1999) as well as Andrade et al. (2012) found that children with ADHD displayed problems in encoding social cues when they were presented with vignettes of social interactions; encoding deficits were uniquely associated with ADHD and not explained by comorbid conduct or internalizing problems.

Some evidence suggests that misinterpretations of peers’ intentions may contribute to cue encoding problems. When presented with stories of social interactions, North American children with ADHD show difficulty in understanding why a character performed a certain action and in inferring cause and effect relationships between story events (Lorch, Milich, Astrin, & Berthiaume, 2006). In a Spanish sample, Miranda, García, and Soriano (2005) similarly found that children with ADHD created less coherent and organized story narratives relative to typically developing children. Although story comprehension deficits have been most postulated to relate to the academic problems of children with ADHD, some research theorizes that these same deficits may also pertain to social impairment. That is, if children with ADHD cannot interpret the causal structure of events in a story, they presumably also have difficulty predicting (and understanding) why a peer would act in a certain fashion (Leonard, Milich, & Lorch, 2011; Sibley, Evans, & Serpell, 2010).

Once children accurately detect and encode social cues in conversations, the next step is to generate and ultimately, to enact socially skilled, effective responses toward peers (Crick & Dodge, 1994; Fontaine, 2010). For example, children must respond with comments that follow the topic of conversation to keep communication going. North American children with ADHD also demonstrate difficulties in this area, interrupting conversations and making impulsive statements (de Boo & Prins, 2007; Landau & Milich, 1988). In addition, the replies given by children with ADHD are characterized by limited vocabulary and deficient language pragmatics (Leonard et al., 2011). Finally, their responses in conversations may be less prosocial and more hostile, demonstrated in observed peer situations (Gardner & Gerdes, 2013; Hodgens, Cole, & Boldizar, 2000) as well as in their responses to hypothetical social scenarios (Andrade et al., 2012; Mikami, Lee, Hinshaw, & Mullin, 2008). A similar tendency may occur among Spanish children with ADHD. As related in García et al. (2011), Miranda, Presentación, and López (1994) presented Spanish children with hypothetical vignettes involving peer situations and asked how they would respond. Relative to typically developing peers, children with elevated hyperactivity generated poorer response strategies—suggesting the presence of similar deficits cross-culturally.

The extent to which children remember details from the conversation may relate to their skillful responses to peers, as well as predict their likelihood of having skillful conversations with the same peers in the future. However, when asked to retell a story, North American children with ADHD provide less information, are more disorganized, and generally make more mistakes in recall relative to comparison peers (Flory et al., 2006; Lorch et al., 2006), a pattern also demonstrated by Spanish children with ADHD (Miranda et al., 2005). In fact, some research specifically links deficient memory for social conversations to limitations in the executive functions of children with ADHD (Huang-Pollock, Mikami, Pfiffner, & McBurnett, 2009).

Assessment of Social Skills

Most studies assessing the social skills of children with ADHD rely upon questionnaires completed by parents, teachers, and the children themselves; occasionally, studies use peer nominations (whereby peers are asked which classmates engage in unskilled behavior) or observation in peer interactions. However, the questionnaire and sociometric measures are instruments that evaluate children’s social skills indirectly via the opinions given by informants, methodologies which have certain limitations. Parents, teachers, and peers are influenced by expectations and show halo effects when rating children’s social behaviors (Mikami, Chi, & Hinshaw, 2004; Podsakoff, MacKenzie, & Podsakoff, 2012); children with ADHD tend to inflate their self-ratings of their own social competence (Hoza et al., 2004). Observational measures can offer protection from some rater biases if observers are kept impartial and free from expectancy effects (Podsakoff et al., 2012).

Nonetheless, all aforementioned methods (adult informant, self, or peer reports, and observations) share the limitation that they fail to consider the ways in which the social skills displayed by children with ADHD may be affected by the behaviors of the peers involved in the interaction. Yet, research suggests that peers’ actions toward children with ADHD may elicit (or maintain) some of the socially unskilled behavior seen in children with ADHD. For instance, one study found that experimentally manipulated rejecting behaviors from peers led to children displaying more maladaptive and poorer social skills in response, a finding that was mediated by increases in the rejected children’s negative emotions (Nesdale & Lambert, 2007). Peers may be biased to treat children with ADHD in a negative, rejecting fashion. In studies where boys were paired for play sessions, for some dyads (randomly selected), researchers provided one of the boys the information that the partner with whom he was about to interact had ADHD (Harris, Milich, Corbitt, Hoover, & Brady, 1992; Harris, Milich, & McAninch, 1998). Observers, unaware of this information, judged the boys for whom their partners had been told that they had ADHD to have poorer social skills relative to the boys for whom partners had been given no such expectation (Harris et al., 1992; Harris et al., 1998).

These important findings demonstrate how peers’ behaviors may influence the social skills displayed by the child with ADHD, underscoring the usefulness of assessing children in a standardized peer situation when measuring social skills. The use of a computer simulation may address some of these concerns, because it is possible to integrate video and social input in a computer to create a controlled virtual environment. Importantly, youth in Spain commonly use online chatting to interact socially (e.g., see Grabowicz, Ramasco, Moro, Pujol, & Eguiluz, 2012) making this a relevant medium for assessing social skills.

In recent years, a number of studies have assessed the conversational skills of North American children with ADHD by means of computerized programs. Ohan and Johnston (2007) examined girls’ social interactions with simulated peers in a computer game. Findings showed that girls with ADHD and Oppositional Defiant Disorder gave more aggressive responses relative to girls with ADHD only and typically developing girls. By contrast, girls with ADHD only presented with awkward behaviors and a lack of prosocial responses. Likewise, Mikami, Huang-Pollock, Pfiffner, McBurnett, and Hangai (2007) created a computerized “Chat Room Task,” whereby children interacted with simulated peers. Results showed that in comparison with typically developing children, those with both ADHD–Inattentive Type (ADHD-I) and ADHD–Combined Type (ADHD-C) gave fewer on topic, elaborated responses. Furthermore, children with ADHD-C made more hostile comments, whereas children with ADHD-I interacted less in general and recalled less about the conversations after the chat session.

As referenced above, studies about the social skills of Spanish children with ADHD are scarce. Moreover, all studies in Spanish populations to date, with the exception of Miranda et al. (2005, 1994), rely exclusively on the judgments of peers, parents, or teachers. These are indirect measures of social functioning, which are more susceptible to being affected by the cultural context in which measures are collected. The use of a computerized assessment tool with standardized prompts is an alternative means of evaluation that may provide a more objective assessment of social skills, to facilitate the cross-cultural comparison of social impairment in ADHD populations.

Aims and Hypotheses

We compared the social skills of Spanish children with ADHD with those of a typically developing sample using a Spanish adaptation of a computerized “Chat Room” simulation task (Mikami et al., 2007), in which children are asked to respond to standardized prompts from peers. On the basis of research suggesting that parents and teachers rate children with ADHD to have poorer social skills in both Spanish and North American samples, we hypothesized that Spanish children would display a similar pattern of social skills deficits in the Chat Room Task as evidenced in Mikami et al. (2007). Specifically, relative to typically developing children, we hypothesized that Spanish children with ADHD would (a) detect fewer social cues, (b) show more difficulties generating responses that follow the topic of peers’ conversation, (c) provide less elaborated responses, (d) give a lower proportion of prosocial responses, (e) give a higher proportion of hostile responses, and (f) display poorer memory for the conversation upon completion of the Chat Room Task.

Method

Participants

Participants were 52 Spanish children between 8 and 12 years of age. Twenty-four children had clinical diagnoses of ADHD and the other 28 formed a typically developing comparison group. The mean age of the children with ADHD was 9.50 years and that of the comparison children was 9.64 years, with no differences between groups in age, t(52) = 0.39, p = .698; level of schooling, t(52) = 0.268, p = .790; or Full-Scale IQ, t(40) = 0.03, p = .979. Most of the children with ADHD were males (n = 20 boys; 83%), and a similar gender breakdown was achieved in the comparison sample (n = 21 boys; 75%; see Table 1).

Table 1.

Demographics of ADHD and Comparison Groups.

Variable	Comparison (n = 28)M (SD)	ADHD (n = 24)M (SD)	Effect size (d)	Omnibus test
Age	9.64 (1.34)	9.50 (1.29)	0.05	t(1, 52) = 0.39
Boys:Girls	21:7	20:4		χ²(1, N = 52) = 0.54
IQ	95.89 (7.56)	95.81 (11.89)	0.00	t(1, 40) = 0.03
Reading comprehension	11.44 (2.61)	7.57 (2.96)	0.57	t(1, 37) = 4.59**
Typing skills	24.49 (17.34)	50.48 (38.78)	0.40	t(1, 47) = −2.94**
Total comments made	21.13 (9.37)	19.68 (12.27)	0.07	t(1, 45) = 0.66

Note. Values in the table are raw score means, unadjusted for covariates, with standard deviations in parentheses.

p < .05. **p < .01.

Inclusion criteria for the children with ADHD were based on those used by Ohan and Johnston (2007) in their computerized assessment task. Specifically, (a) children had been previously diagnosed with ADHD after a comprehensive evaluation by a healthcare professional (i.e., psychologist, psychiatrist, pediatrician), and copies of these reports were provided to the study team; (b) parents confirmed that the child currently met the diagnostic criteria for ADHD-C as specified in the Diagnostic and Statistical Manual of Mental Disorders (4th ed., text rev.; DSM-IV-TR; American Psychiatric Association, 2000), based on parent ratings of the presence of at least six of nine inattention and six of nine hyperactive/impulsive symptoms (each symptom rated on a Likert-type scale from 0 = never to 3 = very often, where scores of 2 or 3 indicated symptom endorsement) and confirmation that symptoms had appeared before the age of 7 and had a duration of greater than 6 months; (c) children had a Full-Scale IQ score of 75 or more as estimated by the Vocabulary and Block Design subtests (see Sattler & Dumont, 2004) on the Spanish version of the Wechsler Intelligence Scale for Children, 3rd edition–Revised (WISC-III-R; Wechsler, 1993); and (d) children had an absence of psychosis, neurological damage, or sensory or motor deficits, as reported by parents. Teachers’ ratings were not used to confirm ADHD diagnoses because most children in our ADHD sample were taking medication during the school day, such that their teachers were unable to report on unmedicated behavior. Indeed, 72.7% of the ADHD sample were medicated; all medicated children were taking stimulant preparations. Before undertaking the measures in the current study, medication was withdrawn 48 hr prior to the evaluation for all medicated children.

Inclusion criteria for the comparison children were that they needed (a) to be free from any psychological disorder, including, but not limited to ADHD, as reported by school personnel; (b) to be displaying normal academic progress as reported by school personnel; and (c) to have an estimated Full-Scale IQ of at least 75 as assessed by the WISC-III-R.

Procedure

Participants were recruited with assistance from the Direction Territorial of Education Authorities, the supervisory and governing organization for School Psycho-pedagogical Services in the province of Castellón, Spain. School Psycho-pedagogical Services consists of expert psychologists who are responsible for assessing and diagnosing children with possible behavioral and learning difficulties at schools. These referral sources provided the research team with a list of 30 children with diagnoses of ADHD (distributed across nine schools in Castellón), whom the research team contacted. Of these 30 potential children with ADHD, 4 did not meet all study inclusion criteria and another 2 children changed schools before data collection could be completed, leaving a final sample of 24 children with ADHD. As well, the Local Education Authorities in Castellón selected a sample of 30 typically developing children at random who were in the same age range and had the same gender distribution of children with ADHD, and who did not have a diagnosis on record for any psychological or learning problem (including, but not limited to, ADHD). Of these 30 potential typically developing children, 2 moved out of the province of Castellón before data collection could be completed, leaving a final sample of 28 comparison youth.

All families provided a written consent to study procedures, which were approved by a university review board. All children (ADHD and comparison) completed study measures at school, in individual soundproof testing rooms with the examiner. For the children with ADHD, two testing sessions (each lasting about 40-60 min) were typically scheduled, because of their issues with attention and behavior. The comparison children typically completed the testing battery in one 60-min session.

Measures

Reading comprehension

Because the chat room requires children to read text, it was important to assess and covary children’s reading ability when analyzing results. As such, participants were administered the text comprehension subtest of the Reading Processes Assessment Battery–Revised (PROLEC-R; Cuetos, Rodriguez, Ruano, & Arribas, 2007), a commonly administered and well-normed reading achievement test assessing nine components of reading, of which text comprehension is one component. The PROLEC-R is used to identify children with significant reading difficulties. The text comprehension subtest is composed of four texts of different lengths (90-130 words) and types (expository and narrative) that children are instructed to read. All texts contained new content for children, so that children’s comprehension was not influenced by previous knowledge. After the child reads each text, the examiner asks the child to provide verbal answers to four questions about the content the child has just read. Each response is awarded 1 point if correct and 0 if incorrect; the total score each child can obtain therefore ranges between 0 and 16 points.

Typing skills

Because the Chat Room Task requires typing, it was also important to assess children’s speed and familiarity with typing, so as to use this variable as a covariate. Children’s typing speed was evaluated by asking them to type three sentences that were dictated by the examiner (Hola me llamo Juan; Me gustan los helados; Tengo la DS y el juego de Mario). The time taken to type all three sentences was recorded by the computer in milliseconds. Children were allowed to type with just one finger, provided that they could do so at a reasonable speed.

Social skills

We applied the computerized Chat Room Task used by Mikami et al. (2007), adapted into Spanish. The same computer interface and prompts were used, but all words were translated into Spanish. The Spanish adaptation was carried out by a computer engineer from the Universitat Jaume I of Castellón and a lecturer in Translation and Interpreting from the Universidad of Salamanca. The computer engineer programmed the software to recognize the participants’ writing and spelling mistakes in Spanish. A pilot test was carried out on four children to improve the artificial intelligence of the software application and to correct possible errors that might appear in the Spanish adaptation. The translation lecturer reviewed the translation of the software and, with assistance from three raters, also adjusted the Spanish expressions to match the English ones and evaluated the translation as culturally correct with the use of natural language.

The Chat Room Task simulates a virtual conversation held between four friends in a chat room to plan a birthday party. Participants are seated in front of a computer screen and keyboard. To increase children’s engagement in the chat room and their perceptions of the realism of the task, participants first enter their name and select a picture to represent themselves. The participants then see their name and picture appear on the computer screen alongside the names and pictures of four other age- and gender-matched children (who are simulated by the computer program). The participants are told that the other children are already friends and are having a conversation. Each child (including the participant) has his or her own color, and any messages that each child types consistently appear in this color.

Importantly, the computer program generates the same conversation between the children for each participant. As such, the program provides a controlled stimulus to which participants are free to respond in their own unique ways. Participants read the friends’ dialogue and are encouraged by the research assistant to type in responses to join the conversation. On average, the entire conversation in the chat room takes approximately 10 min. Once participants finish the interaction in the Chat Room Task, the computer application produces a full transcript of the conversation, including all responses the participant may have made (and when they occurred), for the research team.

The transcripts were coded by a team of three professional psychologists (who had previously attended a 5-hr seminar to train them on coding procedures), following the coding system that was used in Mikami et al. (2007). These coders were kept unaware of children’s diagnostic status. Each transcript was assigned to be coded by two of the three team members, to compute inter-rater reliability. The final score assigned to the child represented the mean of the scores given by the two raters. A detailed description of the chat room as well as all coding procedures can be found in Mikami et al. (2007). Following Mikami et al. (2007), we coded the following:

Detection of social cues. This assesses whether the participant picked up on key social cues from the peers to ask questions about certain topics (e.g., when the peers talk about being allergic to certain foods, did the child ask what kind of food they would want at the party). There were 13 such points in the transcript where the peers dropped strong hints about something, and the child’s response at each point was scored (0 = unsuccessful; 1 = successful response). Inter-rater reliability was excellent (κ = .92).

Generating on-topic responses. This assesses whether responses were on topic with peers’ conversation (e.g., when peers ask the participant, “What movies do you like?” did the child respond with an answer that fits the question). There were also 13 such points in the transcript where the peers asked the participant a direct question, and the child’s response at each point was scored (0 = not on topic; 1 = on topic). κ = .95.

Elaboration of responses. For each answer provided by the participant, this code assesses the extent to which the child has given a more elaborated response. For example, after each peer says hello and states his or her name, if the child says only “hello” this is considered an on-topic response (as assessed in the previous variable indicating on-topic responses), but if the child says “hi, my name is Ruben” this answer is more elaborated. Each response was scored on a 1 to 3 Likert-type scale where higher values indicate better elaboration. Kappa for this variable was .90.

Prosocial responses. The total number of prosocial (supportive, friendly) comments made at any point in the Chat Room Task was calculated (e.g., “Have a good birthday”). Inter-rater reliability for this continuous variable was calculated via intraclass correlation coefficients (ICCs); reliability was good (ICC = .86). Then, the proportion of prosocial responses was calculated by taking the number of prosocial comments divided by the number of total comments made by that participant. We note that children with ADHD and comparison children generated a similar number of total comments (see Table 1).

Hostile responses. The total number of hostile (bragging, disparaging) statements made at any point in the Chat Room Task was calculated (e.g., “That’s stupid”; “I have 1 million video games, bet you don’t.”). Inter-rater reliability for this variable was good (ICC = .84). Then, the proportion of hostile responses was calculated by taking the number of hostile comments divided by the number of total comments made by that participant.

Memory for the conversation. We calculated the correctness of children’s answers to 14 objective, factual questions (sample question: What does the birthday child want to play at the party?) regarding the content of the conversation that had just occurred. Each question was scored on a 3-point scale (0 = incorrect; 1 = partially correct; 2 = fully correct). Internal consistency for the 14 questions in our sample was acceptable (α = .65). Inter-rater reliability for this variable was also good (ICC = .98).

Data Analytic Plan

Data analyses were conducted using the computerized software application SPSS 21.0.

The Kolmogorov–Smirnov test was carried out on all study variables; results suggested that the distributions of all variables could be considered normal (p values ranging from .06 to .93).

The main study hypotheses were tested using ANCOVA procedures to compare the social skills of the children with ADHD with those of comparison children, including the covariates of reading comprehension and typing skills. Effect sizes for ADHD versus comparison groups were computed using Cohen’s (1988) d and interpreted on the following metric: small = 0.2, medium = 0.5, large = 0.8.

Results

Descriptive Statistics

Table 1 presents data for children with ADHD and comparison children on demographic measures. Groups did not differ in age, gender, and IQ, or in the number of total comments made in the Chat Room Task. However, consistent with a large body of research documenting academic impairments among children with ADHD (Loe & Feldman, 2007), comparison children had higher scores in reading comprehension and in typing skills relative to children with ADHD.

ADHD and Comparison Group Differences in Social Skills

Table 2 displays the group means and results of all analyses comparing the children with ADHD with the comparison children on the variables from the Chat Room Task.

Table 2.

Performance on Chat Room Task Variables in ADHD and Comparison Groups.

Variable	Comparison (n = 28)M (SD)	ADHD (n = 24)M (SD)	Effect size (d)	Omnibus test^a
Detection of social cues	9.22 (2.17)	8.95 (2.55)	0.05	F(1, 41) = 3.91
Generating on-topic responses	8.00 (2.15)	5.36 (2.38)	0.50	F(1, 41) = 3.90
Elaboration of responses	19.60 (5.49)	15.00 (4.58)	0.41	F(1, 41) = 2.53
Prosocial responses	3.69 (2.29)	1.52 (0.81)	0.53	F(1, 41) = 4.57*
Hostile responses	0.08 (0.29)	1.18 (1.26)	0.51	F(1, 41) = 3.05
Memory for the conversation	14.60 (6.39)	7.34 (5.24)	0.53	F(1, 41) = 3.29*

Note. Values in the table are raw score means, unadjusted for covariates, with standard deviations in parentheses.

Tested via omnibus ANCOVAs with covariates of reading comprehension and typing skills.

p < .05. **p < .01.

Detection of social cues

After statistical control of covariates, no significant differences were observed between the ADHD and comparison groups in detecting social cues.

Generating on-topic responses

Despite group means in the direction suggesting that children with ADHD did a poorer job following the topic of conversation relative to comparison children, these differences were not significant after statistical control of covariates.

Elaboration of responses

There were no differences between ADHD and comparison groups in the elaboration of the responses given during conversation sequences, after accounting for covariates.

Prosocial responses

There were significant differences between children with ADHD and comparison children, such that children with ADHD were observed to provide a smaller proportion of prosocial responses, after accounting for covariates. The effect size for this comparison was large.

Hostile responses

ADHD and comparison groups did not significantly differ in the proportion of hostile responses given, after accounting for covariates.

Memory for the conversation

Children with ADHD demonstrated significantly poorer memory for the conversation relative to comparison children, after accounting for covariates. This comparison had a medium effect size.

Exploratory Analyses

It may be argued that statistically controlling for reading comprehension and typing skills is overcontrol (Miller & Chapman, 2001), because these variables are influenced by ADHD symptoms and not randomly distributed across ADHD and comparison samples (Loe & Feldman, 2007). Because the current study is the first to use the Chat Room paradigm in a Spanish sample, as an exploratory step, we reconducted all analyses to examine ADHD versus comparison group differences without the covariates of reading comprehension and typing skills. These exploratory results suggested that children with ADHD, relative to comparison children, may be poorer in generating on-topic responses in the conversation, t(45) = −3.89, p = .00; may give less elaborated responses, t(45) = −3.05, p = .00; may have a lower proportion of prosocial responses, t(45) = −4.12, p = .00, and a higher proportion of hostile responses, t(45) = 4.08, p = .00; and may demonstrate poorer memory for the conversation, t(45) = 4.16, p = .00. However, without the inclusion of covariates, groups did not differ in detection of social cues, t(45) = 3.72, p = .71.

Discussion

The current study is the first to use a virtual computerized program to compare the social skills of children with ADHD with those of comparison children in a Spanish population. This methodological approach attempted to control for peers’ contributions to children’s social interactions, by presenting all participants with a standardized stimulus to which variability in children’s skillful responses was coded. Findings suggested that Spanish children with ADHD, relative to comparison children, displayed a lower proportion of prosocial responses in the conversation and demonstrated less memory for the conversation afterward. These group differences held after statistical control of the covariates of reading comprehension and typing skills. By contrast, Spanish children with ADHD and comparison children did not differ in detecting social cues, generating on-topic responses in the conversation, elaboration of responses, or proportion of hostile responses given, after statistical control of covariates. Still, means for all variables were in the direction such that children with ADHD displayed poorer social skills, and—although these results must be interpreted with caution—all but one of these comparisons (detection of social cues) reached statistical significance without the covariates of reading comprehension and typing skills.

These results can be considered in the context of the Social Information Processing Model (Crick & Dodge, 1994; Fontaine, 2010). Similar to the results obtained by Mikami et al. (2007) in a North American sample, we did not find significant differences between Spanish children with ADHD and comparison children in the detection and encoding of social cues. It may be that the first stage of processing social information is not impaired in ADHD populations. Yet, other studies have shown that children with ADHD are not capable of detecting social cues in videotaped social situations (Matthys et al., 1999) or in social vignettes (Andrade et al., 2012). The discrepancy between the results may be attributable to the use of different methodologies. For instance, the Chat Room paradigm does not provide visual social feedback or require children to attend to and integrate visual social feedback into their interpretations of social cues. However, children in the Chat Room paradigm must attend to and process social cues in real time, something that may not be captured by the other methodologies.

Results for the next step of the Social Information Processing Model, generating effective responses, suggested that children with ADHD may show impairment in this area. With the inclusion of the covariates of reading comprehension and typing skills, Spanish children with ADHD gave a significantly lower proportion of prosocial responses, although they did not differ from comparison children on generation of on-topic responses, elaboration of responses, or proportion of hostile responses given. However, without the inclusion of covariates, Spanish children with ADHD demonstrated poorer functioning on all four measures in this construct. Interestingly, these differences existed in light of no overall group differences in numbers of responses offered, suggesting that the problem for children with ADHD (at least, the Combined presentation) may not be in social reticence but rather in the content of their responses. The deficiencies in reading comprehension and typing skills may have accounted for some of the group differences in generation of effective responses. Nonetheless, we note that children with ADHD have been documented to generate ineffective responses in other settings where reading and typing are not required. For instance, there is consistent research suggesting that because of their deficient inhibition, children with ADHD-C interrupt conversations and make comments more impulsively (de Boo & Prins, 2007; Gardner & Gerdes, 2013).

Interestingly, our results also suggest that Spanish children with ADHD may give fewer prosocial responses but may not differ in hostile responses (at least after covariates were included) from comparison children. Our findings are in line with those obtained by Ohan and Johnston (2007) and other studies as reviewed by Nijmeijer et al. (2008), which show that children with ADHD have difficulty in adapting their behavior to social situations that can help or benefit others, and demonstrate fewer cooperative social behaviors. However, it is notable that other research, including the original Chat Room study by Mikami et al. (2007), has found that the differences between North American children with ADHD (at least the Combined presentation) and comparison children lie predominantly in hostile responses and not in prosocial responses. Nonetheless, because prosocial behavior may independently predict friendship (Blachman & Hinshaw, 2002; Erhardt & Hinshaw, 1994), this may be an important impairment.

The results that Spanish children with ADHD have greater difficulty in remembering the conversation compared with comparison children align with those obtained by Mikami et al. (2007) in the North American sample. Deficient working memory in children with ADHD may contribute to this result; in fact, several recent studies specifically link working memory deficits to social problems in ADHD (Kofler et al., 2011; Tseng & Gau, 2013) and to difficulty remembering social conversations (Huang-Pollock et al., 2009). We speculate that the Chat Room Task requires children to attend to fast-paced information presented by four peers at once (a realistic simulation of real-life group conversations), and then hold the obtained information in memory long enough to be able to generate a socially skilled response.

In summary, the current study results suggest an overall similarity between the social skills impairments of Spanish children with ADHD and the impairments observed in the North American sample of Mikami et al. (2007) in the Chat Room Task. This may suggest that a common model of social impairment applies to children with ADHD across cultures. In both samples, the children with ADHD did not demonstrate deficits in encoding social cues relative to comparison children, but they did display more problems in producing socially skilled responses and in retaining memory for the conversation. The North American ADHD sample observed in Mikami et al. (2007), however, demonstrated problems in a larger number of indicators pertinent to production of socially skilled responses (at least, after statistical control of covariates). Future research should examine the extent to which our divergent results may be attributable to the small sample size and associated lack of statistical power in the current study, or because of potential cross-cultural differences.

There are several limitations to this study that might be addressed in future work. Namely, the sample was small, consisted of children aged 8 to 12, and included only children with ADHD-C; importantly, other work including that of Mikami et al. (2007) in the original Chat Room Task has suggested significant differences in social functioning among children with ADHD-C relative to ADHD-I. As such, caution should be exercised in making any generalizations from these results, especially to other age groups or ADHD presentations. In addition, we did not consider children’s conduct problems or internalizing symptoms; these common comorbidities may affect social information processing and responses (Andrade et al., 2012; Matthys et al., 1999; Mikami et al., 2008). Third, although the Chat Room Task provided a controlled stimulus (to which children were free to respond in their unique ways), there are many aspects of the computerized task that differ from daily, face-to-face peer interactions. For instance, children cannot receive visual feedback or tone of voice cues from their peers in the computerized setting, nor must they provide visual feedback or tone of voice cues in their responses. Finally, given that the Chat Room Task remains a new assessment tool, a more extensive validation study in Spanish is warranted.

In conclusion, the current study represents a step forward in improving technologies to assess social skills among children with ADHD cross-culturally, because of the ability of the Chat Room Task to standardize the stimulus being presented to participants.

Footnotes

Acknowledgements

We would like to thank the territorial Department of Education of Castellón, School Psycho-Pedagogical Services, and the schools in the province of Castellón (Spain). We also thank Adri Khalis for his help in formatting the manuscript.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This research was supported in part by PSI2008 06121/PSIC from the Spanish Ministry of Science and Innovation.

Author Biographies

Rosa García-Castellar is a full professor in the Department of Methodology, Social, Educational and Developmental Psychology of Universitat Jaume I Castellón (Spain). Rosa García-Castellar researches evaluation and intervention for children with special needs, especially ADHD.

Pilar Jara-Jiménez is a full professor in the Department of Methodology, Social, Educational and Developmental Psychology of Universitat Jaume I Castellón (Spain). Pilar Jara-Jiménez’s research focuses on methodology in general.

Desirée Sánchez-Chiva is a professional psychologist and PhD student in the program of social and family intervention of the Universitat Jaume I Castellón (Spain).

Amori Y. Mikami is an associate professor in the Department of Psychology at the Unversity of British Columbia (Canada). Amori Y. Mikami studies peer relationship impairments among youth with ADHD.

References

American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text rev.). Washington, DC: Author.

Andrade

B. F.

Tannock

(2014). Sustained impact of inattention and hyperactivity-impulsivity on peer problems: Mediating roles of prosocial skills and conduct problems in a community sample of children. Child Psychiatry & Human Development, 45, 318-328. doi:10.1007/s10578-013-0402-x

Andrade

B. F.

Waschbusch

D. A.

Doucet

King

MacKinnon

McGrath

P. J.

. . . Corkum

(2012). Social information processing of positive and negative hypothetical events in children with ADHD and conduct problems and controls. Journal of Attention Disorders, 16, 491-504. doi:10.1177/1087054711401346

Blachman

D. R.

Hinshaw

S. P.

(2002). Patterns of friendship among girls with and without attention-deficit/hyperactivity disorder. Journal of Abnormal Child Psychology, 30, 625-640. doi:10.1023/a:1020815814973

Catalá-López

Peiró

Ridao

Sanfélix-Gimeno

Gènova-Maleras

Catalá

M. A.

(2012). Prevalence of attention deficit hyperactivity disorder among children and adolescents in Spain: A systematic review and meta-analysis of epidemiological studies. BMC Psychiatry, 12(1), Article 168. doi:10.1186/1471-244X-12-168

Cohen

(1988). Statistical power analysis for the behavioral sciences (2nd ed.). Hillsdale, NJ: Lawrence Earlbaum Associates

Crick

N. R.

Dodge

K. A.

(1994). A review and reformulation of social information-processing mechanisms in children’s social adjustment. Psychological Bulletin, 115, 74-101. doi:10.1037/0033-2909.115.1.74

Cuetos

Rodriguez

Ruano

Arribas

(2007). PROLEC-R. Batería de evaluación de los procesos lectores, revisada Madrid [Readers processes assessment battery – Revised. PROLEC-R]. Madrid: TEA Editions.

de Boo

G. M.

Prins

P. J. M.

(2007). Social incompetence in children with ADHD: Possible moderators and mediators in social-skills training. Clinical Psychology Review, 27, 78-97. doi:10.1016/j.cpr.2006.03.006

10.

Erhardt

Hinshaw

S. P.

(1994). Initial sociometric impressions of attention-deficit hyperactivity disorder and comparison boys: Predictions from social behaviors and from nonbehavioral variables. Journal of Consulting and Clinical Psychology, 62, 833-842. doi:10.1037/0022-006x.62.4.833

11.

Fabiano

G. A.

Pelham

W. E.

Jr. Waschbusch

D. A.

Gnagy

E. M.

Lahey

B. B.

Chronis

A. M.

. . . Burrows-MacLean

(2006). A practical measure of impairment: Psychometric properties of the impairment rating scale in samples of children with attention-deficit hyperactivity disorder and two school-based samples. Journal of Clinical Child & Adolescent Psychology, 35, 369-385. doi:10.1207/s15374424jccp3503_3

12.

Fernandez-Jaen

Fernandez-Mayoralas

D. M.

Lopez-Arribas

Garcia-Savate

Muniz-Borrega

Pardos-Veglia

. . . Munoz-Jareno

(2011). Attention deficit hyperactivity disorder and its relation to social skills and leadership evaluated with an evaluation system of the behavior of children and adolescents (BASC). Actas Españolas de Psiquiatría, 39(6), 339-348.

13.

Flory

Milich

Lorch

Hayden

Strange

Welsh

(2006). Online story comprehension among children with ADHD: Which core deficits are involved? Journal of Abnormal Child Psychology, 34, 850-862. doi:10.1007/s10802-006-9070-7

14.

Fontaine

R. G.

(2010). New developments in developmental research on Social Information Processing and antisocial behavior. Journal of Abnormal Child Psychology, 38, 569-573. doi:10.1007/s10802-010-9400-7

15.

García

Jara

Sánchez

(2011). School context: Family satisfaction and social competence of children with Attention-Deficit/Hyperactivity Disorder (ADHD). Procedia—Social & Behavioral Sciences, 29, 544-551. Retrieved from https://dx-doi-org.web.bisu.edu.cn/10.1016/j.sbspro.2011.11.274

16.

García

Presentación

M. J.

Siegenthaler

Miranda

(2006). Estado sociométrico de los niños con trastorno por déficit de atención con hiperactividad subtipo combinado [The sociometric status of children with the combined subtype of attention deficit hyperactivity disorder]. RevNeurol, 42(Suppl. 2), S013-S017.

17.

Gardner

D. M.

Gerdes

A. C.

(2013). A review of peer relationships and friendships in youth with ADHD. Journal of Attention Disorders. Advance online publication. doi:10.1177/1087054713501552

18.

Grabowicz

P. A.

Ramasco

J. J.

Moro

Pujol

J. M.

Eguiluz

V. M.

(2012). Social features of online networks: The strength of intermediary ties in online social media. PLoS ONE, 7(1), Article e29358. doi:10.1371/journal.pone.0029358

19.

Harris

M. J.

Milich

Corbitt

E. M.

Hoover

D. W.

Brady

(1992). Self-fulfilling effects of stigmatizing information on children’s social interactions. Journal of Personality and Social Psychology, 63, 41-50. doi:10.1037/0022-3514.63.1.41

20.

Harris

M. J.

Milich

McAninch

C. B.

(1998). When stigma becomes self-fulfilling prophecy: Expectancy effects and the causes, consequences, and treatment of peer rejection. In Brophy

(Ed.), Advances in research on teaching (pp. 243-272). Greenwich, CT: JAI Press.

21.

Hinshaw

S. P.

Owens

E. B.

Zalecki

Huggins

S. P.

Montenegro-Nevado

A. J.

Schrodek

Swanson

E. N.

(2012). Prospective follow-up of girls with attention-deficit/hyperactivity disorder into early adulthood: Continuing impairment includes elevated risk for suicide attempts and self-injury. Journal of Consulting and Clinical Psychology, 80, 1041-1051. doi:10.1037/a0029451

22.

Hodgens

J. B.

Cole

Boldizar

(2000). Peer-based differences among boys with ADHD. Journal of Clinical Child Psychology, 29, 443-452. doi:10.1207/s15374424jccp2903_15

23.

Hoza

Gerdes

A. C.

Hinshaw

S. P.

Arnold

L. E.

Pelham

W. E.

Jr. Molina

B. S. G.

. . . Wigal

(2004). Self-perceptions of competence in children with ADHD and comparison children. Journal of Consulting and Clinical Psychology, 72, 382-391. doi:10.1037/0022-006x.72.3.382

24.

Hoza

Mrug

Gerdes

A. C.

Hinshaw

S. P.

Bukowski

W. M.

Gold

J. A.

. . . Arnold

L. E.

(2005). What aspects of peer relationships are impaired in children with attention-deficit/hyperactivity disorder? Journal of Consulting and Clinical Psychology, 73, 411-423. doi:10.1037/0022-006x.73.3.411

25.

Huang-Pollock

Mikami

Pfiffner

McBurnett

(2009). Can executive functions explain the relationship between attention deficit hyperactivity disorder and social adjustment? Journal of Abnormal Child Psychology, 37, 679-691. doi:10.1007/s10802-009-9302-8

26.

Kofler

M. J.

Rapport

M. D.

Bolden

Sarver

D. E.

Raiker

J. S.

Alderson

R. M.

(2011). Working memory deficits and social problems in children with ADHD. Journal of Abnormal Child Psychology, 39, 805-817. doi:10.1007/s10802-011-9492-8

27.

Landau

Milich

(1988). Social communication patterns of attention-deficit-disordered boys. Journal of Abnormal Child Psychology, 16, 69-81. doi:10.1007/bf00910501

28.

Leonard

M. A.

Milich

Lorch

E. P.

(2011). The role of pragmatic language use in mediating the relation between hyperactivity and inattention and social skills problems. Journal of Speech, Language, and Hearing Research, 54, 567-579. doi:10.1044/1092-4388(2010/10-0058)

29.

Loe

I. M.

Feldman

H. M.

(2007). Academic and educational outcomes of children with ADHD. Journal of Pediatric Psychology, 32, 643-654. doi:10.1093/jpepsy/jsl054

30.

Lora

J. A.

Moreno

(2008). Perfil social de los subtipos del Trastorno por déficit de atención con hiperactividad. Apuntes de Psicología [Social profile of the subtypes of attention hyperactivity deficit disorder], 26(2), 317-329.

31.

Lorch

E. P.

Milich

Astrin

C. C.

Berthiaume

K. S.

(2006). Cognitive engagement and story comprehension in typically developing children and children with ADHD from preschool through elementary school. Developmental Psychology, 42, 1206-1219. doi:10.1037/0012-1649.42.6.1206

32.

Matthys

Cuperus

J. M.

Engeland

H. V.

(1999). Deficient social problem-solving in boys with ODD/CD, with ADHD, and with both disorders. Journal of the American Academy of Child and Adolescent Psychiatry, 38, 311-321. doi:10.1097/00004583-199903000-00019

33.

Mikami

A. Y.

(2010). The importance of friendship for youth with attention-deficit/hyperactivity disorder. Clinical Child and Family Psychology Review, 13(2), 181-198. doi: 10.1007/s10567-010-0067-y

34.

Mikami

A. Y.

Chi

T. C.

Hinshaw

S. P.

(2004). Behavior ratings and observations of externalizing symptoms in girls: The role of child popularity with adults. Journal of Psychopathology and Behavioral Assessment, 26, 151-163. doi:10.1023/b:joba.0000022107.47515.85

35.

Mikami

A. Y.

Huang-Pollock

C. L.

Pfiffner

L. J.

McBurnett

Hangai

(2007). Social skills differences among attention-deficit/hyperactivity disorder types in a chat room assessment task. Journal of Abnormal Child Psychology, 35, 509-521. doi:10.1007/s10802-007-9108-5

36.

Mikami

A. Y.

Lee

S. S.

Hinshaw

S. P.

Mullin

(2008). Relationships between social information processing and aggression among adolescent girls with and without ADHD. Journal of Youth and Adolescence, 37, 761-771. doi:10.1007/s10964-007-9237-8

37.

Miller

G. A.

Chapman

J. P.

(2001). Misunderstanding analysis of covariance. Journal of Abnormal Psychology, 110, 40-48. doi:10.1037/0021-843x.110.1.40

38.

Miranda

García

Soriano

(2005). Habilidad narrativa de los niños con trastorno por déficit de atención con hiperactividad [Narrative skills in children with attention deficit hyperactivity disorder]. Psicothema, 17, 227-232.

39.

Miranda

Presentación

M. J.

López

(June, 1994). Social relationships in aggressive and attention-deficit hyperactivity disordered children. Paper presented at the International Symposium Attention Deficit Disorder (ADHD), Amsterdam, The Netherlands.

40.

Nesdale

Lambert

(2007). Effects of experimentally manipulated peer rejection on children’s negative affect, self-esteem, and maladaptive social behavior. International Journal of Behavioral Development, 31, 115-122. doi:10.1177/0165025407073579

41.

Nijmeijer

J. S.

Minderaa

R. B.

Buitelaar

J. K.

Mulligan

Hartman

C. A.

Hoekstra

P. J.

(2008). Attention-deficit/hyperactivity disorder and social dysfunctioning. Clinical Psychology Review, 28, 692-708. doi:10.1016/j.cpr.2007.10.003

42.

Ohan

Johnston

(2007). What is the social impact of ADHD in girls? A multi-method assessment. Journal of Abnormal Child Psychology, 35, 239-250. doi:10.1007/s10802-006-9076-1

43.

Podsakoff

P. M.

MacKenzie

S. B.

Podsakoff

N. P.

(2012). Sources of method bias in social science research and recommendations on how to control it. Annual Review of Psychology, 63, 539-569. doi:10.1146/annurev-psych-120710-100452

44.

Polanczyk

de Lima

M. S.

Horta

B. L.

Biederman

Rohde

L. A.

(2007). The worldwide prevalence of ADHD: A systematic review and metaregression analysis. The American Journal of Psychiatry, 164, 942-948. doi:10.1176/appi.ajp.164.6.942

45.

Sattler

Dumont

(2004). Assessment of children: WISC-IV and WPPSI-III supplement. San Diego, CA: Jerome Sattler.

46.

Sibley

M. H.

Evans

S. W.

Serpell

Z. N.

(2010). Social cognition and interpersonal impairment in young adolescents with ADHD. Journal of Psychopathology and Behavioral Assessment, 32, 193-202. doi:10.1007/s10862-009-9152-2

47.

Tseng

W.-L.

Gau

S. S.-F.

(2013). Executive function as a mediator in the link between attention-deficit/hyperactivity disorder and social problems. Journal of Child Psychology and Psychiatry, 54, 996-1004. doi:10.1111/jcpp.12072

48.

Wechsler

(1993). Escala de inteligencia para niños revisada. Madrid, Spain: TEA [Wechsler Intelligence Scale for Children. Madrid: TEA Editions].

49.

Whalen

C. K.

Henker

Collins

B. E.

McAuliffe

Vaux

(1979). Peer interaction in a structured communication task: Comparisons of normal and hyperactive boys and of methylphenidate (Ritalin) and placebo effects. Child Development, 50, 388-401.